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Location, location, location

Where you live affects when regular breast cancer screening starts

Concerned about an aunt who’d been diagnosed with breast cancer, Vicky Yakabuski—then in her thirties—got a referral from her doctor for a mammogram, a habit she got into keeping each year. At age 46, Yakabuski learned she had breast cancer. “It was a treacherous time,” says the homemaker, now 48, who lives in Stouffville, Ont., and it was hard on her husband and two daughters. After a mastectomy and chemotherapy, she’s doing better; she and supporters (dubbed “Team Victorious”) raised $15,200 in October’s Canadian Breast Cancer Foundation CIBC Run for the Cure. As for the mammogram, she says, “it saved my life.”

Breast cancer is the most commonly diagnosed cancer among Canadian women, yet for those under 50, the benefits of regular mammograms remain controversial. Because it’s less common in younger women—the annual risk of developing it at 40 is half what it is at 50—experts warn that regular testing can actually do more harm than good. (Women in their forties, who have denser breast tissue, are more likely to get false positive results.) Others insist it saves lives: one B.C. study showed that providing women in their forties with regular mammograms reduced deaths from breast cancer by 25 per cent. Even so, medical bodies offer conflicting advice, and screening programs vary between provinces. This “creates confusion,” says Beth Easton of the Canadian Breast Cancer Foundation (CBCF), and can put women at risk.

Last week, two U.S. groups—the American College of Radiology and the Society of Breast Imaging—recommended that average women start getting annual mammograms at age 40. This followed on the heels of other guidelines, issued in November by the U.S. Preventive Services Task Force (PSTF), which recommended against routine mammograms at that age. For every 1,904 women aged 40 to 49 screened for 10 years, the PSTF said, just one cancer death would be avoided, compared to one death for every 1,339 women aged 50 to 59. Screening younger women carries potential harms, including anxiety, unnecessary biopsies, and radiation. (Exposure from a screening mammogram is about the same as what a person is exposed to on a flight from Canada to Australia and back, according to the B.C. Cancer Agency.)

The PSTF guidelines—which also said that women aged 50 to 75 should have mammograms every two years, instead of every year—sparked outrage across the U.S., where they were panned as confusing, condescending or dangerous. (The same body recommended regular mammograms for women in their forties in 2002.) “We were really, really surprised” by the task force’s position, says Dr. Phil Evans, president of the Society of Breast Imaging. While the PSTF was concerned about mitigating harm, he notes, “the biggest harm, in my mind, is not finding a treatable cancer.” Martin Yaffe, senior scientist of imaging research at Toronto’s Sunnybrook Health Sciences Centre, calls the task force’s stance “ridiculous.” (The PSTF panel later backtracked slightly, noting that the choice to begin regular mammography before age 50 is an “individual one.”)

In Canada, the picture isn’t any clearer. The Canadian Cancer Society says women aged 50 to 69 should get a mammogram every two years; those in their forties should talk to a doctor (clinical breast exams are recommended for both groups). Both the CBCF and the Canadian Association of Radiologists promote screening mammograms for women in their forties. “Twenty per cent of cancers occur in women under 50,” notes Easton.

While each province has a breast cancer screening program—which sends notices to women to get a mammogram every year or two, depending on their age, without requiring a doctor’s referral—the age at which they can enter the program varies. In B.C., for example, women can self-refer starting at age 40. But in Quebec, they have to wait until they’re 50. (Some provinces allow women in their forties to enter the program with a doctor’s note.) In Ontario, the age of regular screening “has always been 50,” says Dr. Verna Mai, provincial lead, public health at Cancer Care Ontario. Although they can’t participate in the screening program, women in their forties can still get mammograms, she adds—they just have to consult with a doctor first, and won’t have access to the program’s benefits, like regular recalls.

But there’s a difference between getting a diagnostic mammogram (with a doctor’s referral) and participating in a regular screening program, insists Yaffe, who says he’s been petitioning the province “for well over 10 years” to accept women in their forties. Over 70 per cent of women with breast cancer have no risk factors, other than gender and age, says the B.C. Cancer Agency.

Not yet 50 years old, Yakabuski got a doctor’s note for each of her mammograms, setting up an unofficial “screening program” of her own. “I truly believe, if women are concerned, they should go for a mammogram,” she says. “It’s a lifesaving test.” M

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